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r--er- <br />_-77 t T ., <br />• .. <br />Sacramento=E ui ment'Maintenance'Company•Inc`• <br />2533 Connie Drive Calif. Contr. License r5023T7 <br />Sacramento, CA 95815 Wo 1 60227 <br />PLEAS 9RINT 6 Data Chart for Tank System Tightness Test Statonl 6100 <br />PLEASE PRINT <br />1. OWNER P.,erly❑ <br />Tank(a) <br />Arco <br />P -0 -Box 5811 San Mateo <br />Ca. Courtland Holeman <br />Name Address Representative Teteph— <br />Name - Address Representative Telephone <br />2. OPERATOR <br />Arco <br />25775 <br />Patterson <br />•Address <br />Pass <br />Rd. Tracy <br />_ <br />Name <br />Telephone <br />3. REASON FOR <br />TEST <br />(Explain Fully) <br />New Tnstallation <br />4. WHO REQUESTED <br />TEST AND WHEN <br />Sam <br />Name Title Company or Affiliation <br />pate <br />Address <br />Telephone <br />_ <br />5. TANK INVOLVED <br />Use additional Anes <br />for mantidded tanks <br />Identity by Direction <br />Capacity <br />o 0 f3 <br />Brand/Supplier <br />ARCO <br />(trade <br />Appro. Age <br />Stset/Fiberglass <br />12 m;lDina <br />o <br />V <br />14 /0 <br />_ <br />d <br />Go <br />/- <br />6. INSTALLATIONF <br />DATA <br />Location <br />JSLIar7%�S <br />North mala. driveway. <br />W station.. etcsuction,Rer <br />cover <br />C06CR6fri <br />Concrete. Bleck Top. <br />Earth. t <br />Fills <br />L// <br />Si:e, Ttelu make. Drop <br />tubes, moFb <br />Vents <br />01 <br />bizs. tk%d <br />siphon" <br />Uh l �r /a �� <br />sfI c,r ►'J <br />MRIh tanks? <br />Pumps , <br />-fo N <br />e/ <br />riro, <br />Maa LnownRear <br />7. UNDERGROUND <br />WATER <br />Depth to the waterab+. <br />< <br />< li <br />Is Ire water over the tank? <br />Ely" IRNo <br />8. FILL -UP <br />ARRANGEMENTS <br />Tanks to be sed hr. one Arranged by <br />Extra product a lop otr aro tun fink Water. How and who to provide? Consider No Leel. <br />Name <br />Telephone <br />Terminal or other oonact <br />for notice or NgMy <br />Company Name <br />Telephone <br />9. CONTRACTOR, <br />MECHANICS, <br />any other Contractor <br />Involved <br />.. <br />. <br />10. OTHER <br />INFORMATION <br />OR REMARKS <br />c v �S. <br />T�Ezj 11APote nL Vfflii _ ' '— "o <br />'fig —gQ T <br />A n P014gnf; <br />Additional bnbrmstlon on any kers above. Officials or others lobe advised when Offing Is In progre" or oompl ted. Vbaora or obwoors preewa drxkrg ft*L eta _ <br />Tests were made on the above tank systems In accordance with test procedures prescribed for•> <br />11. TEST RESULTS as detailed on attached test charts with results as follows: _.. <br />Tank Identification Tight . Leakage welted ` Date Tested <br />obo [: L#Qfl t p .<. <br />o tK c o <br />/D. Oso /A/. Aorrm'%".v %/LTO L..I a9 1 i 1atin <br />12. SENSOR 13. This Is to certify that these tank systems were tested on the date(s) shown. Those Indicated as "Tight" meet the criteria established by <br />CERTIFICATION the National Fire Protection Association Pamphlet 329. <br />Tedw0clarr It is the responsibility of the owner and / or operator of this system to immediately advise state and local authorities of any, <br />Dns / Implied hazard and the possibility of any reportable ponution to the environment as a result of the Indicated failure of this <br />1. (-�-A G�%�L� system. Heath Consultants Incorporated and/or SACRAMENTO EQUIPMENT MAINTENANCE COMPANY. INC. <br />r /• ! / y �/ ( Z(� G assume any responsibility or liability for any loss of produ the env onment. <br />serial No. of Thermal Certificalt" 1 <br />senna <br />(_ i <br />Certification 1 Tank Bonar/[)Perab ✓ Date <br />� 101 <br />